Module 2: Refugee Health (Approximate time required: 30 minutes) Mental Illness Please watch the following short video: What is mental illness? Refugees generally experience an increased risk of mental illness compared to host populations. (Nosè, 2017). Common types of mental illness among refugees include depression, anxiety, and PTSD. The following is a quick overview of these three types of mental illness: Anxiety: Anxiety is a normal part of life that everyone experiences, but having intense and excessive/persistent fear or worry about everyday situations is not normal (Mayo Clinic, 2018). Symptoms of anxiety include experiencing sudden, intense anxiety or fear and can lead to acute panic attacks. These feelings can be difficult to control and might begin to interfere with daily life. Some people experience an increased heart rate, sweating, rapid breathing, trouble sleeping and gastrointestinal problems. The root cause of anxiety is complex and not completely known, but medical and inherited traits and experiencing intense or traumatic life events are all potential factors (Mayo Clinic, 2018a). Depression: Major depressive disorder or clinical depression is a type of mental illness that can cause feelings of sadness and/or a loss of interest in normal activities, irritability, sleep disturbances, tiredness, feelings of worthlessness or guilt, trouble concentrating, and changes in appetite (Mayo Clinic, 2018b). It is often accompanied by multiple emotional or physical problems and can inhibit individuals from getting out or accomplishing basic day-to-day activities. Common methods of treatment include medication and psychotherapy (Mayo Clinic, 2018b). PTSD: Post-traumatic stress disorder (PTSD) is a mental illness triggered by traumatic events that were either witnessed or experienced personally (Mayo Clinic, 2018c). There are four main symptoms of PTSD: intrusive memories, avoidance, experiencing a more negative attitude, and changes in emotional and physical reactions. Those suffering from PTSD might also experience nightmares, flashbacks, uncontrolled thoughts or intense anxiety. (Mayo Clinic, 2018c). Symptoms of PTSD may surface when an individual is reminded of their past traumatic experiences, but those suffering from PTSD can get better with time, external help, and the development of coping strategies (Mayo Clinic, 2018c). Note: People can experience multiple mental health disorders at one time, and experiencing one disorder can worsen or influence other mental conditions. How can we help? When working and interacting with refugees, many wonder how to effectively support those dealing with mental health issues. First, understanding the causes and symptoms of different types of mental illness is important. Learning what methods, practices, and techniques have been proven effective in supporting refugees in overcoming mental health challenges is essential to successfully working together to improve their mental state. Simply encouraging positive thinking without understanding the backgrounds and personal struggles/mental conditions they are experiencing is not helpful for those suffering from any type of mental illness. Refugees come from a variety of backgrounds, but all have been forced to flee their own countries out of fear for their lives, health, and freedom (See Module 1). Since language barriers, cultural norms, and root causes of displacement can differ dramatically, knowing how to help can be challenging. The following paragraphs provide general methods used in supporting refugees suffering from mental illness. Art Therapy There are many refugees, especially children, that have difficulty talking about their traumatic experiences. This can lead to difficulty in coping with the past. Using methods of creative expression such as art therapy have often been used as a method allowing children to express their thoughts, feelings, and perceptions (Rousseau et al., 2005).One scholarly article explored multiple methods of creative expression, including sand play, art and storytelling, and drama workshops. For example, the art and storytelling method helped children share stories that often included a personal drawing and tales of their families and home countries. This helped create a positive dialogue between the children and their parents, encouraged them to see the positive parts of their heritage and past, and often improved self esteem. It also helped those facilitating to understand the young refugees and their backgrounds and behaviors (Rousseau et al., 2005). The article concluded that there are four key aspects that should be included in creative expression: 1. The construction of a safe space 2. Acknowledgement and appreciation of diversity 3. Establishment of continuity 4. The transformation of adversity Furthermore, there are three central points to always include when developing your own creative expression programs: 1. Offer verbal and nonverbal ways for participants to express themselves (find ways to overcome language barriers) 2. Try to represent cultural diversity so all can be included and participate 3. Ensure a safe place to work through issues, both personally and in small group discussions Finally, remember as a teacher to always be sensitive and supportive (Rousseau et al., 2005). In conclusion, when conducting your own music and art classes, consider ways to help the children feel safe, appreciated, and proud of their culture. Include multiple ways for participants to express themselves (verbally and artistically) and make sure everyone is included. Encourage group discussion as well as individual expression. Support local religious and community organizations One systematic review concluded that having welcoming links within ethnic communities or religious organizations can help to buffer some of the negative effects of refugee life (Kirmayer et al., 2011). Though we are not allowed to proselytize or offer religious advice, religious and community organizations available to refugees can act as cultural support systems for them (Kirmayer et al., 2011). On your own trips, consider affirming refugees in participating in their own cultural and religious activities, and in staying actively involved with their organizational support systems. Supporting those suffering with PTSD PTSD is one of the most studied mental illnesses among refugees, likely due to the fact that refugees in high income countries (like many countries in Europe) are up to 10 times more likely to experience PTSD than their host populations (Nosè et al, 2017). Refugees are more continuously exposed to traumatic experiences, and diagnosing PTSD can be difficult as temporary distress is to be expected after such events. As a result, trauma for refugees can be quite different in severity and duration compared to other populations (Nosè et al, 2017). Professional treatment is ideal, but often unavailable. What we do know is that cultural and language barriers, struggling to trust foreign staff, and feeling socially marginalized can aggravate the factors contributing to PTSD (Nosè et al, 2017).As volunteers, three methods can be implemented in helping refugees cope and to decrease the effects of PTSD. These include: 1. Overcoming language barriers by teaching a new language to the refugees 2. Earning and maintaining trust with refugees 3. Helping refugees feel socially accepted and validated Appropriate Interactions and Conversation Give the person space. Avoid crowding or startling the person. This can make a traumatized person feel threatened (Smith, 2019). Don’t pressure the person into talking. It can be very difficult for people with PTSD to talk about their traumatic experiences. For some, it can even make them feel worse (Smith, 2019). While you shouldn’t push a person with PTSD to talk, if they do choose to share, try to listen without expectations or judgments. Make it clear that you’re interested and that you care, but do not offer any advice. It’s the act of listening attentively that is helpful for them, not what you say (Smith, 2019). A person with PTSD may need to talk about the traumatic event over and over again. This is part of the healing process, so avoid the temptation to tell the person to stop rehashing the past and move on (Smith, 2019). Some of the things they tell you might be very hard to listen to, but it’s important to respect their feelings and reactions. If you come across as disapproving or judgmental, it will be harder for them to open up to others in the future (Smith, 2019). However, if you are very uncomfortable with the interaction, it is always appropriate to say, “I’m uncomfortable with this conversation and would like to stop.” Communication pitfalls to avoid Do Not… ● Give easy answers or casually tell the person everything is going to be okay ● Stop the person from talking about their feelings or fears ● Offer unsolicited advice or tell the person what they “should” do ● Invalidate, minimize, or deny the person’s traumatic experience ● Give ultimatums or make threats or demands● Make the person feel weak because they aren’t coping as well as others ● Tell the person they were lucky it wasn’t worse ● Take over with your own personal experiences or feelings In conclusion: Understanding the causes and symptoms of different types of mental illness is important. You should now have a basic understanding of a few of the most common types of mental illness such as anxiety, depression and PTSD. Applying the methods, practices, and techniques discussed above will increase your ability to support refugees dealing with mental illness. Feel free to review this module again before your trip.